Health

Summary

Mr C attended the Western Infirmary Hospital a number of years ago when he was experiencing dizziness and migraines. Mr C was referred for an MRI scan to investigate his condition further. Several years later, Mr C was diagnosed with a schwannoma (a tumour on the nerve tissue). His original MRI scan images were reviewed and he was told that the tumour had been visible at that time.

Mr C complained that there was a failure to investigate the tumour when he first attended hospital as it had been visible in his MRI scan. We took independent advice from a consultant neuroradiologist (a radiologist who specialises in the use of radioactive substances, x-rays and scanning devices for the diagnosis and treatment of diseases of the nervous system). We found that in retrospect, the tumour was visible in the original MRI scan. However, as it was small and not clearly defined, we found it was reasonable that it was not identified at that time. We found that even if the tumour had been identified then, it was reasonable for it not to have been reported as it was only borderline abnormal. We also found that Mr C did not yet have any sign of a neck tumour or any symptoms relating to it. We did not uphold this aspect of the complaint.

Mr C also complained that the board failed to provide an appropriate response to his complaint. We found that their response did not accurately identify all of his concerns or provide a reasonable response to them. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not accurately identifying and providing an appropriate response to all aspects of his complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints responses should accurately identify and provide a reasonable response to all the issues of concern.

Summary

Ms C complained about the care and treatment provided to her late mother (Mrs  A) at Vale of Leven hospital. Mrs A had been admitted with a fractured hip after a fall and remained in hospital for four months before her death. Ms C complained about a number of medical issues, including the timing of the diagnosis of the hip fracture, hydration and nutrition, diagnosis of dementia and end of life care.

We took independent advice from a consultant physician. We found that whilst the documentation of the initial assessment of Mrs A should have been more detailed, her care and treatment was reasonable. We found that Mrs A's hydration and nutrition was managed appropriately and in line with national guidelines, that the diagnosis of dementia was appropriately handled and that her care was holistic and reasonable given her declining health. We did not uphold Ms C's complaint; however, we made a recommendation to the board regarding the documentation of the initial assessment.

Recommendations

What we said should change to put things right in future:

• Patients with an unwitnessed fall should have a full neurological (nervous system) and musculoskeletal (muscles and bones) system examination documented on admission.

Summary

Ms C complained about the care and treatment provided to her mother (Mrs A) when she attended Queen Elizabeth University Hospital for a graft repair of a brain aneurysm (a procedure in which a catheter is passed through a small cut in the groin area to an artery and then to the blood vessel in the brain where the aneurysm (a bulge in the blood vessel wall) is located in order to repair it using coils (spirals of wire) which stabilise the aneurysm). Ms C complained that there had been complications and that there was a delay in the vascular team (specialists in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels) coming to assist with the repair. Ms C also said that during Mrs A's recovery, the vascular team had not reviewed Mrs A.

We took advice from a consultant in interventional neuroradiology (a specialist in minimally invasive image-based technologies and procedures used in diagnosis and treatment of diseases of the head, neck, and spine) and a vascular surgeon. We found that the graft repair of brain aneurysm procedure was carried out reasonably, and the leakage of blood where the blood vessel had been closed is a well recognised complication of this procedure. We found that the complication had been managed in a timely and appropriate way, and that the care provided to Mrs A after her surgery was reasonable. However, we found that consent for the graft repair of brain aneurysm had only been taken on the day of surgery. We considered that this should have occurred earlier in order to allow Mrs A to fully understand the procedure and risks. We also found that there was no evidence that Mrs A had been provided with an information leaflet prior to the surgery. Finally, we found that the management plan after the procedure was not adequately communicated to the relevant team. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A that the consent process was not initiated at an earlier point than on the day of the procedure, that she was not provided with an information leaflet prior to the procedure, and that the management plan after the procedure was not adequately communicated to the relevant team. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• The consent process for graft repair of a brain aneurysm should be initiated at an earlier point than on the day of the procedure (unless there is an emergency situation) and information leaflets should be provided at the appropriate time.
• The plan regarding which team are responsible for the patient should be clear.

Summary

Mrs C complained about the medical care and treatment her late mother (Mrs A) received when she attended the emergency department at Queen Elizabeth University Hospital. Mrs C said that no blood or blood gases tests were carried out before Mrs A was discharged.

We took independent advice from a consultant in emergency medicine. We found that there had been no indication to carry out blood or blood gases tests when Mrs A had attended the emergency department and that the care and treatment she received had been reasonable. Therefore, we did not uphold the complaint.

Summary

Mr C complained about the board's treatment of his Basal Cell Carcinoma (BCC, a type of skin cancer). Having undergone three initial operations to remove a BCC, he required a further operation to remove a recurrence around nine years later. Mr C complained that the board failed to treat him properly when they initially carried out the surgery.

We took independent advice from a consultant dermatologist (a doctor who specialises in the diagnosis and treatment of skin disorders).

We found that the pathology report of the third procedure should have raised concerns that the tumour may recur. We noted that Mr C had been offered a follow-up appointment, but did not seem to have been warned of the possibility of recurrence. We considered that reasonable treatment options following the pathology from the third procedure would have included consideration for Moh's surgery (surgery where thin layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains) and/or follow-up in one to two years with the warning that the tumour could return.

The board confirmed that following the third procedure, Mr C was reviewed then discharged to his GP two months later. We found that there was no record on file that he was advised the tumour may return. There was also no record of the board having considered treatment with Moh's microsurgery, although they confirmed that it was available at the time in question. Therefore, we upheld Mr  C's complaint.

Although we upheld the complaint, we noted the board's comments that had they provided a longer follow-up over two years, this would not have detected or prevented the later occurrence of the BCC. We accepted that it was unlikely this would have detected the recurrence. We also noted that there was no evidence that the surgeries were carried out incorrectly or that they contributed to the recurrence.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to consider possible Moh's microsurgery treatment, to arrange an appropriate timeframe for follow-up and to advise of the risk of recurrence of the tumour. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

Summary

Mrs C complained about the care and treatment that her child (Child A) received from the orthopaedic department (the branch of medicine that deals with diseases and injuries of the musculoskeletal system) and the rheumatology department (the branch of medicine that deals with rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments) at the Royal Hospital for Sick Children, Yorkhill.

We took independent advice from a consultant spinal surgeon and a rheumatologist. We found that:

Mrs C was not informed that the possibility of a spinal x-ray had been discussed following Child A's appointment with the orthopaedic department.

there was no record of the referral that the orthopaedic department made to physiotherapy.

there was no record of the discussions within the orthopaedic department about the risk of doing an x-ray on Child A's spine.

there was no record of the referral that physiotherapy made to rheumatology.

the plan to watch Child A's back for changes did not happen.

We upheld Mrs C's complaints about the care and treatment provided following Child A's referral to the orthopaedic department and the rheumatology department.

Mrs C also complained about the way the board handled her complaint. We found that the board failed to acknowledge Mrs C's complaints in writing within three working days and failed to keep Mrs C updated about the reason for the delay in responding to her complaints and provide a revised timescale for a response. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Child A for failing to provide Child A with reasonable care and treatment following their referral to the orthopaedic department and the rheumatology department, for failing to communicate reasonably with Mrs C and for failing to handle Mrs C's complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Patients and/or their parent/guardian should be informed when an x-ray is being considered following the identification of scoliosis (abnormal lateral curvature of the spine).
• Clear records of inter-disciplinary referrals and discussions should be kept.
• Clear records should be kept of discussions about the risk of performing an x-ray on a child's spine.
• Clear records of inter-disciplinary referrals and discussions should be kept.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.

Summary

Having been diagnosed with lung cancer, Mrs C complained that she had been attending the practice for years with breathlessness and she considered that she should have been referred for specialist investigation sooner. The practice noted that Mrs C was fully investigated for intermittent complaints of breathlessness, and that she was diagnosed with chronic obstructive pulmonary disease (COPD - a disease of the lungs in which the airways become narrowed). The practice said that when Mrs C presented with new symptoms (a nocturnal cough along with worsening breathlessness) she was promptly investigated and the diagnosis of lung cancer was made. They did not consider there were previously any suggestive symptoms that might have prompted an earlier referral for suspicion of cancer. They noted that the grading of the cancer indicated it had been detected relatively early, and they considered that her COPD was the more likely source of her breathlessness.

We took independent advice from a GP. We found that it was reasonable for the practice to have made a presumptive diagnosis of COPD and that they sought to manage this within the primary care setting. The adviser said that the practice could have considered requesting a chest x-ray and respiratory referral around ten months earlier than they did, as Mrs C had reported worsening breathlessness (not just on exertion but also at rest). However, the adviser did not consider it unreasonable for them not to have taken that approach. They noted Mrs C was referred for breathing tests at that time, which confirmed the COPD diagnosis. On balance, we did not uphold the complaint.

Summary

Mr C complained about the care and treatment he received from the ear, nose and throat (ENT) service at Inverclyde Royal Hospital. Specifically, that he was not examined thoroughly and that staff were dismissive of his symptoms being related to sinusitis (inflammation of the lining of the sinuses).

We took independent advice from a consultant ENT surgeon experienced in treating cases requiring sinus surgery. We found that Mr C's symptoms had been appropriately investigated, in particular with CT scans (a scan that uses x-rays and a computer to create detailed images of the inside of the body) and endoscopy (direct visualisation by camera). There was no evidence to show that Mr C had bacterial or fungal sinusitis or any evidence of a sinus tumour. We considered that Mr C's care and treatment was reasonable and appropriate and did not uphold his complaint.

Summary

Mr C complained about the medical care and treatment that his wife (Mrs A) received from the board. Mrs A had a diagnosis of cancer and had a number of admissions to Aberdeen Royal Infirmary over a two month period. We took independent advice from a consultant clinical oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that:

• Mrs A was discharged from hospital before the results of a stool sample were obtained and while she was experiencing diarrhoea
• there are no written records of the phone calls that the doctor had with Mrs  A or her GP following a positive result for Clostridium difficile (a bacterium that causes diarrhoea and more serious intestinal conditions)
• Mrs A was not readmitted to hospital as soon as the Clostridium difficile result became available.

We considered the medical care and treatment to be unreasonable and upheld this aspect of Mr C's complaint.

Mr C also complained about the nursing care and treatment that Mrs A received. We took independent advice from a nursing adviser. We found that:

• the board's response in relation to hand gels was inaccurate in that hand gels are ineffective when caring for patients with Clostridium difficile
• Mrs A's personal hygiene requirements were not recorded consistently and daily records were not kept to indicate what personal hygiene assistance Mrs A had received or had been offered
• nursing staff did not appear to adhere to the Infection Control Policy.
• nursing staff did not record how they knew about Mrs A's shingles (a viral infection that causes a painful rash) diagnosis or whether this information had been passed on to the admitting doctor.

We considered the nursing care and treatment to be unreasonable and upheld this aspect of Mr C's complaint.

Mr C also complained that the board did not handle his complaint reasonably. We found that the board failed to keep Mr C updated about the reason for the delay in responding to his complaint and to provide a revised timescale for completion. We also found that the board's complaint response did not address all the points that Mr C raised. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to provide Mrs A with reasonable medical and nursing care and treatment and for failing to handle his complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Nursing staff should be aware that alcohol based hand rubs or hand gels are ineffective in removing Clostridium difficile spores and that hand-washing is an important aspect of preventing the spread of Clostridium difficile.
• Personal hygiene requirements should be recorded clearly and consistently. There should be daily recordings to indicate what personal hygiene assistance patients have received or have been offered.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs.

Summary

Mr C had been in contact with mental health services for a number of years and was informed by his current psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness) that he had a diagnosis of borderline personality disorder. Mr C complained that his previous psychiatrist had failed unreasonably to diagnose him with this and provide the appropriate treatment.

We took independent advice from a medical adviser. We found that the standard of communication in relation to the diagnosis was unreasonable and that this led to uncertainty and distress for Mr C. While, we did not find this had an adverse effect on his management or treatment, we recognised that not learning of his diagnosis until recently lead to a great deal of uncertainty and distress. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in record-keeping and communication. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• The clinician involved should reflect on this complaint and findings at their next appraisal.
• The board should ensure that clinicians follow the relevant guidance when diagnosing and discussing personality disorders with patients.